MEDICARE: PATRICIA MIRIAM RUS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1275148280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA MIRIAM RUS PA-C

Provider Business Mailing Address
First Line	:	23615 N 105TH DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85383-1195
Country	:	US
Telephone Number	:	623-221-7731
Fax Number	:

Provider Business Practice Location Address
First Line	:	722 N MONTEZUMA ST
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-2002
Country	:	US
Telephone Number	:	928-237-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2020
Last Update Date	:	08/13/2021

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